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No. 3
FEE
C®MMONWE-ALT14®f MASSACHUSETTS
YARMOUTH HEALTH DEPT.
Board of Health, 14c ROUTE 28 , MA.
APPLICATION FOP, DISPOSAL �WfffeNMVMON PERMIT
Application for a Permit to Constlt( ) Repair(-) Upgrade(Pf"Abandon() - ❑ Complete System ❑ Individual Components N�
(14T,,�.%..
Location 8 / %AFT
Owner's Name
Map/Parcel# -'6_19/76
Address
Lot# 17
Telephone#
Installer's Name F W. /I'I
Designer's Name --eVq,#14141,1e-444,7-
Address E 915
Address Tq�),go X2,4 d-owz LN r/t/N/S
Telephone# ��83$S�-gq�3
Telephone# 5Z)$38S'Z,4 ;&6 --
Type of Building 3 zo Lot Size 171-:5.00 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 1330 gpd Calculated design flow 3.40'4-
40'4 Design flow provided 34014' gpd
Plan: Date il�5� o4- Number of sheets O N E-- Revision Date
Title P9.eP6SED Or_,,0-nC1)eK16/V
Description of Soil(s) SEFPI-414
Soil Evaluator Form No. 29 7Z Name of Soil Evaluator—/ AAIVA Jct qft Date of Evaluation mA6164—
DESCRIPTION OF REPAIRS OR ALTERATIONS "._ 0,"
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre s t a the a operation until a Certificate of CoIpm
en issued by the Board of health.
Signed Date
Inspections
%/ /
No. yCOMMO � LT14 Of MASSAC14US�ETTS FEE �j`1 ).-M
Board of Health, MA.
CERTIFICA� 'OF COMPLIANCE
Description of Work: ❑ Individual Component(s) VIComplete System
The �h
by: C
at
has been in
application
Installer
System; Constructed ( ), Repaired ( ), Upgraded ( Abandoned ( )
design plans/as-built plans relating to
Designer: 1 f t .lJ Inspector:
The issuance of this permit shall not be, construed as a guarantee that the system
No.
at
vuVtunctuon as aesigneat
FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, N'Am. 4l
Ij
DISPOSAL SYSTEM CONSTRUCTION PERMIT
is hereby granted to, Construct( ) Repair(
Upgrade(/ Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No.datedc
Provided: Construction shall be completed within t�s of the date of this permit. All local condid s must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date / ;,24 Board of Health ;
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